FEBRUARY 11, 2019
ORLANDO, FL
www.HIMSSConference.org
#EngageHealth
Dignity Health Boosts Medication
Adherence with SMART on FHIR
Agenda
• Dignity Health – Who we are
• Issue identification and solution design
• SMART on FHIR definition
• Why is the topic important?
• Solution description
• Solution metrics
• SMART on FHIR Integration
Objectives
• Illustrate the challenges associated with achieving medication adherence,
especially with diverse patient populations
• Identify strategies to leverage SMART on FHIR with an aggressive
implementation timeline
• Explain how to integrate medication instructions into a portal that provides
comprehensive discharge information
• Demonstrate the importance of providing access to information and
applications at the most convenient times in the clinician’s workflow
• Evaluate potential return on investment associated with providing medication
instruction via a dedicated discharge portal
Dignity Health: Who we are
39 hospitals, and 400 care sites across 22 states
Statistically-speaking:
• 8,500+ acute care beds
• 600+ skilled nursing beds
• 9,000+ physicians
• 62,000+ employees
Ministry Alignment:
CommonSpirit Health will include more than 700 care sites and 139 hospitals, with approximately 159,000 employees across 28 states. Total combined annual
revenues are estimated at approximately $30 billion.
Issue Identification and Solution Design
Issue: Dignity Health wanted a solution to improve our HCAHPS scores,
decrease our readmission rates, and broaden our options to communicate in
languages other than English or Spanish.
Solution: Partnered as an early adopter with Cerner and a small start-up
company. The partnership provided an energetic, exciting, and fun opportunity to
integrate with SMART on FHIR to produce a rapid rollout.
What is SMART on FHIR?
Description of SMART on FHIR
• SMART= Substitutable Medical, Applications Reusable Technologies*
• FHIR= Fast Healthcare Interoperability Resources*
• Makes an “app” store for healthcare possible
• Open standards-based technology platform that enables innovators to create
apps which seamlessly and securely run across the health care system
*http://smarthealthit.org/wp-content/uploads/SMART-on-FHIR-White-Paper-for-HIMSS-15-06Apr2015.pdf
What is SMART on FHIR?
Dignity Health facts for SMART on FHIR
• Meducation® was one of the first SMART
on FHIR applications used with our Cerner
platform
• Meducation® has the largest scope of any
other applications currently in use
Why does it matter?
Medication adherence and its impact:
30-50% of medications are not taken at all, or not as instructed
Medication adherence is associated with
• 10% of hospitalizations**
• 26% of ALL avoidable readmissions**
• Poor medication compliance is related to 125,000 deaths/year ***
• Cost of non-adherence is $290 billion/year ****
• 72% of post-discharge adverse events
** Quick Guide to Health Literacy. https://health.gov/communication/literacy/quickguide/Quickguide.pdf
*** Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, Coker-Schwimmer EJ, Rosen DL, Sista P, Lohr KN. Interventions to improve adherence to self-administered
medications for chronic diseases in the United States: a systematic review. Ann Intern Med. 2012 Dec 4;157(11):785–95.
**** NEHI Research Brief-August 2009. Thinking Outside The Pillbox: A System-wide Approach to Improving Patient Adherence for Chronic Disease.” NEHI, 2009
Low Health Literacy is COMMON
• Health literacy is the capacity to obtain,
communicate, process, and understand
basic health information*
• 44 million adult Americans read below
an 8
th
grade reading level**
• IOM estimates one in three Americans
are challenged by complex information
such as
• reading prescription labels
• taking their medications correctly
*Nielsen-BohlmanLT, PanzerAM, HamlinB, KindigDA, eds. Institute of Medicine. Health literacy: a prescription to end confusion. Committee on Health Literacy, Board on Neuroscience and
Behavioral Health. Washington, DC: National Academies Press. April 2004.
**National Institute for Literacy, National Center for Adult Literacy, The Literacy Company, U.S. Census Bureau
Detailed patient education – often
formatted in small font to fit on one page,
provided in one language
*Nielsen-BohlmanLT, PanzerAM, HamlinB, KindigDA, eds. Institute of Medicine. Health literacy: a prescription to end
confusion. Committee on Health Literacy, Board on Neuroscience and Behavioral Health. Washington, DC: National
Academies Press. April 2004.
Typical Patient Education
Personalized Instructions
Reduce
medication
errors with
patient-specific
Instructions
Improve medication
adherence with Regimen
Summary
Demonstrate proper
medication
administration
techniques
through videos
Language Diversity for Printed Patient Education
Patient population language diversity
21% of patients are limited English proficient*
43% speak a language other than English
(in the state of CA)*
Prior to implementation, we were only
able to provide medication education in
English and Spanish upon discharge
Printed Examples: Font and Language Choices
Discharge Instructions & Patient Portal
Discharge instructions are integrated into our EHR discharge instructions
and patient portal
• Write back into patient record
• Drive traffic to help meet Meaningful
Use requirements for 10% patient
electronic access
Retrieved from: http://www.hbs.edu/openforum/openforum.hbs.org/goto/challenge/hbs-hms-health-acceleration-challenge/meducation-delivering-medication-instructions-that-every-
patient-can-understand.1.html
25%
55%
53%
65%
45%
37%
79%
63%
73%
22%
Could ID side
effects
When in the
day
How long to
take
How many
times
Missed a dose
Standard Meducation
52% Improved Understanding & Adherence
Improved Understanding & Adherence
Improved Medication Adherence at VA
65%
43%
39%
21.7%
36%
18%
22.7%
4.5%
0%
10%
20%
30%
40%
50%
60%
70%
…Sometimes forget to
take my heart medicines"
…Am sometimes
careless with how I take
my heart medicines"
…Have trouble
remembering what my
medicines are for"
…Forgot to take my
heart medicine
yesterday"
Patients “Agree or Strongly Agree” that I ...
Baseline 90 days later
77%
Improvement
Retrieved from: http://www.hbs.edu/openforum/openforum.hbs.org/goto/challenge/hbs-hms-health-acceleration-challenge/meducation-delivering-medication-
instructions-that-every-patient-can-understand.1.html
Patient Satisfaction Low Health Literacy
52%
98%
85%
4%
1%
1%
0% 20% 40% 60% 80% 100%
Staff describe medicine…
Tell you what new medicine…
Communication About…
Percentile Rank
Baseline 90 Days Later
HCAHPS Overall Percentile
Increased HCAHPS scores & increased VBP payment in 90 days
Retrieved from: http://www.hbs.edu/openforum/openforum.hbs.org/goto/challenge/hbs-hms-health-acceleration-challenge/meducation-delivering-medication-instructions-that-every-
patient-can-understand.1.html
Meducation Integration with Dignity EHR
Via SMART on FHIR
How the Integration Works
• Integration is via standard FHIR web service
• SMART on FHIR provides a method for apps to launch securely within the EMR
• Users access Meducation as an MPage component from within workflow
Dignity Health Cerner FDB
• Licensed the “Ignite” web
service from Cerner
• Tested the web service
integration
• Configured the FHIR web
service
• Configured Meducation
documents to be made
part of the depart
summary
• Provided testing
support and issue
resolution
Feedback
Nursing
Much more engaged in counseling patients on their meds
Appreciate being able to communicate with patients in their language and
provide multiple font sizes
Creates length to printed discharge instructions
Patients & Caregivers
Better understanding and fewer questions on their instructions
Calendar view ease of use for all
Why Education Matters
Dignity Health mission, vision, and values
If patients do not understand what we are teaching
them, they cannot make the right decisions about their
health and they cannot follow their treatment plan
Patients feel able to manage their health needs; they are
empowered and capable
Patient-centered care - the responsibility is on us to
teach effectively, not the patient’s ability to learn
It improves communication between patients and
clinicians
www.HIMSSConference.org
#EngageHealth
Sarah Toy-Ding &
Tiffany Shields-Tettamanti
